Fistic Medicine: Alves and ‘Brain Irregularity’

If there is a more disturbing word to append to the noun “brain”
than “irregularity,” I don’t know it. The preliminary information
regarding Thiago
Alves’ failure of his pre-fight CAT scan was worrisome; the
additional information indicating that the abnormal finding
involved an artery in the brain was more worrisome. Medical
personnel following the case assumed that the suspicious finding
was an aneurysm, possibly a large one. The recent reports that, in
fact, Alves does not have an intracranial aneurysm provide
reassurance and prompt further questions.

The arterial blood supply to the brain comes from four vessels --
the paired internal carotid arteries and the vertebral arteries
that pass through the cervical vertebrae. These vessels join to
form the circle of Willis: at any point in this circle of arteries,
or in its branches, growth abnormalities can occur. While aneurysms
-- potentially fatal ballooning of the blood vessels -- are one
form of abnormality, it appears Alves has a different vascular
abnormality: an Arteriovenous Malformation.

Arteriovenous Malformations (AVM) are tangled collections of blood
vessels that can occur anywhere in the body. They are generally
benign, but if they compress vital structures or bleed, they can
cause significant damage. An intact AVM in the brain might cause
headaches, seizures or in an extreme case a swelling of the fluid
in the brain known as hydrocephalus. If a cerebral AVM bleeds --
and because these malformed vessels do not have the same structural
integrity of normal arteries, they have a high risk of rupture and
bleeding -- death occurs in approximately 10 percent of cases.

It is not known if participating in combat sports increases the
risk of bleeding. While in theory the brain trauma associated with
blows to the head or the vascular pressure changes associated with
a choke submission might increase the chance of bleeding, the
definitive data simply does not exist. The New Jersey State
Athletic Control Board made the appropriate conservative decision
to prevent Alves from fighting until his malformation has been
further investigated and treated.

There are several options for treatment of an intracranial AVM,
each with benefits and disadvantages depending on where the AVM is
located within the brain. By report, Alves’ malformation is in the
left hemisphere of his brain, and he is scheduled for an angiogram
to delineate exactly what regions of the brain are involved. Once
that is determined, a decision will have to be made whether to
address the malformation with surgery, radiation or
embolization.

Surgery offers the advantage of being able to directly visualize
the abnormality and remove it entirely. It has the profound
disadvantages of requiring a craniotomy, a prolonged recovery
period and possible damage to the brain surrounding the malformed
vessels. If the AVM is on a superficial, non-vital portion of the
brain, surgery is an option -- otherwise, the results could be
catastrophic. Radiation therapy using extremely high energy X-Rays
known as gamma rays can be used to burn the malformed vessels.
There is some associated damage to surrounding brain tissue, but
most patients do very well. Lastly, if the AVM is accessible to a
small intra-arterial catheter, it is possible to fill the tangle of
blood vessels with a thin Platinum fiber. This embolization
procedure clots off the AVM, diminishing the pressure effects on
surrounding tissue and ending the risk of hemorrhage.

Once an AVM is treated, there is no reason why a fighter could not
return to the ring. Surgery would require a long recovery period,
but effective embolization could get a fighter back into the ring
within weeks or months. The risk of bleeding or other serious harm
would be nil. Once the AVM is dealt with, there is no reason for
further care, re-examination or limitation of action. Alves’ future
pre-fight CAT scans will always show the presence of an
abnormality, but with the stipulation of a neurosurgeon or
interventional radiologist to his fitness, his fighting license
should be unaffected. Alves has missed a major fight, but if an
angiogram proves he does in fact have a manageable AVM, there is no
reason -- no medical reason -- he shouldn’t be back in the ring
this summer.

The only remaining concern will be the question of whether it was
fighting itself, either blows to the head or submission chokes,
that caused the apparent AVM. There is no evidence to support the
thesis that brain trauma causes AVMs and no reason to suspect that
standard choking techniques are implicated in the disease. Far more
likely is that the requisite pre-fight CAT scan caught an AVM that
otherwise might never have been detected. Or, in a worse case
scenario, the pre-fight CAT scan caught an AVM before it ruptured;
it may have saved Alves’ life.

While this incident is a hassle for UFC President Dana White and a
disappointment for Alves, it is a success story for MMA. The
discovery of a potentially dangerous “brain irregularity” stands as
a testament to the prudence of the NJSACB and the sport’s interest
in fighter safety. Those responsible for the current safety
precautions should be congratulated, and those working for greater
safety should be encouraged in their efforts.

Matt Pitt is a physician with degrees in biophysics and
medicine. He is board-certified in emergency medicine and has
post-graduate training in head injuries and multi-system trauma. To
ask a question that could be answered in a future article, e-mail
him at mpitt@sherdog.com.